Summary of the Committee to Advise on Tropical Medicine and Travel (CATMAT) Statement on Travelers’ Diarrhea

Abstract

Background: Most travellers' diarrhea (TD) infections occur during travel to low-and middle-income countries. Type of travel, duration of stay, age of traveller and presence of certain medical conditions are important factors to consider for risk of TD. The Committee to Advise on Tropical Medicine and Travel (CATMAT) assembled a TD working group to develop recommendations on prevention and treatment of TD in travellers. This document is a summary of the Statement on Travellers' Diarrhea. Methods: Following a systematic review of the literature, recommendations on the prevention and treatment of TD were developed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology to evaluate data quality, benefits and harms of the intervention, and values and preferences of the traveller. Other recommendations were based on a review of the literature and expert opinion. Recommendations: Using the GRADE methodology, CATMAT concluded that oral cholera vaccine should not be routinely recommended to prevent TD in Canadian travellers. This recommendation was based on moderate quality data that showed this vaccine was not effective in preventing TD in travellers compared to placebo. Bismuth subsalicylate (BSS), fluoroquinolones or rifaximin are options for the prevention of TD based on high-quality data for BSS and fluoroquinolones and moderate evidence for rifaximin. For the treatment of TD, loperamide (alone or in combination with antibiotics), fluoroquinolones, azithromycin and rifaximin are all options, with varying degrees of data quality. Based on available evidence and expert opinion, CATMAT recommends handwashing or the use of hand sanitizer, as well as prudent choice and preparation of food and beverages as best practices for preventing diarrhea while travelling. At this time, a recommendation cannot be made for either the use of probiotics and prebiotics to prevent TD or the use of BSS to treat TD due to insufficient available evidence. Conclusion: With the exception of BSS for prevention of TD (strong recommendation for use), CATMAT conditionally recommends the use of each of the other GRADE-evaluated preventive and therapeutic products assessed in this Statement. These CATMAT recommendations should be considered as options in the prevention and treatment of TD based on the particular situation of the traveller. Preamble The Committee to Advise on Tropical Medicine and Travel (CATMAT) provides the Public Health Agency of Canada with ongoing and timely medical, scientific, and public health advice relating to tropical infectious disease and health risks associated with international travel. The Agency acknowledges that the advice and recommendations set out in this Statement are based upon the best current available scientific knowledge and medical practices, and is disseminating this document for information purposes to both travellers and the medical community caring for travellers. Persons administering or using drugs, vaccines or other products should also be aware of the conten...

Travelers’ Diarrhea: A Clinical Review

“…This is especially so when they have to travel for extended periods by air or ground. The short-term use of loperamide (Imodium) has been approved for the treatment of individuals ≥ 2 years of age with travelers’ diarrhea [52]. Loperamide is an opioid-like agent that is taken orally [53].…”

“…Antimicrobial therapy is effective in reducing the duration and severity of traveler’s diarrhea [52, 60]. For travelers going to moderate and high-risk areas, it might be appropriate to provide them with a short course of a suitable antibiotic with the advice to start antimicrobial treatment should they develop moderate or severe diarrhea [25].…”

“…The dosing schedule (2.1 to 4.2 g per day divided into 4 divided doses to be given with meals and at bedtime) is inconvenient for the traveler because of the large quantities of medication that have to be taken four times a day [2, 71]. Also, bismuth subsalicylate has an unpleasant taste, turns the tongue and stool black, and has the potential for salicylate toxicity and encephalopathy [2, 52]. The medication is not recommended for children or for individuals with aspirin allergy, renal insufficiency, or gout, or for those who are taking anticoagulants, probenecid, or methotrexate.…”

“…Based on randomized controlled trials, a Cochrane review, however, found that there is no significant difference in efficacy between Dukoral vaccine and placebo in the prevention of travelers’ diarrhea [74]. Although there is insufficient evidence to support the routine use of Dukoral vaccine for the prevention of travelers’ diarrhea caused by ETEC [52], some investigators suggest that Dukoral vaccine should be considered for travelers ≥ 2 years of age who will be visiting areas where there are high risk of contracting travelers’ diarrhea caused by ETEC. The vaccine may also benefit those individuals who are at high risk of severe complications, such as those who are immunocompromised, are prone to complications from diarrhea, or have a chronic illness [52, 76].…”

Guideline for the Antibiotic Use in Acute Gastroenteritis

“…All bloody diarrhea is defined as severe [59]. When empirical antibiotic therapy was used for moderate traveler's diarrhea, the treatment was found to decrease the duration of diarrhea by 1.5 days on average [586061], and by 16 - 30 hours for severe traveler's diarrhea [58].…”